Fracture Complications

Systemic Crises - Code Red Alerts

• Hypovolemic Shock:

  • Common in polytrauma. ATLS classification (Class I-IV based on blood loss %: <15%, 15-30%, 30-40%, >40%).
  • Management: ABCDE, O₂, IV fluids (crystalloids, blood products).

• Fat Embolism Syndrome (FES):

  • Long bone/pelvic fractures. Pathophysiology: Mechanical obstruction & chemical pneumonitis.
  • Gurd's Major Criteria (≥2): Respiratory distress, cerebral signs, petechial rash.
  • ⭐ > Classic triad of Fat Embolism Syndrome: respiratory distress, neurological symptoms, and petechial rash.
  • Prevention: Early fracture fixation. Management: Supportive (O₂, ventilation).

• Venous Thromboembolism (VTE - DVT/PE):

  • Virchow's Triad: Stasis, hypercoagulability, endothelial injury.
  • Risk factors: Immobility, surgery, prior VTE. Wells Score (e.g., DVT >3 high risk).
  • Prophylaxis: Mechanical (SCDs), Pharmacological (LMWH, e.g., Enoxaparin 40mg OD).
  • Diagnosis: Doppler US (DVT), CTPA (PE). Treatment: Anticoagulation (Heparin, Warfarin).

Local Limb Threats - Pressure Cookers

• Compartment Syndrome: ↑ Pressure in fascial compartment → ↓ tissue perfusion, ischemia.
  • 📌 6 Ps: Pain (key, on passive stretch), Paresthesia, Pallor, Pulselessness (late), Paralysis.
  • Dx: Clinical; Intracompartmental pressure (ICP) > 30-45 mmHg.

  ⭐ A delta pressure (Diastolic BP - Compartment Pressure) of < 30 mmHg is a strong indication for fasciotomy in compartment syndrome.

  • Tx: Urgent Fasciotomy.
• Acute Vascular Injury:
  • Hard signs (pulsatile bleed, absent pulse, thrill); Soft signs (↓ pulse, history).
  • Dx: ABI < 0.9; Doppler; CT Angio. Tx: Surgical repair.
• Nerve Injury:
  • Seddon: Neuropraxia, Axonotmesis, Neurotmesis.
  • Sunderland: Grades I-V.
• Crush Syndrome: Muscle crush → rhabdomyolysis.
  • Features: Myoglobinuria (dark urine), hyper$K^+$, ↑CK, AKI.
  • Tx: Aggressive IV fluids, urine alkalinization.

Healing Hijacked - Union & Infection

• Fracture Infection (Osteomyelitis):
  • Timing: Acute (<2 wks), Chronic (>2 wks).
  • Signs: Local pain, swelling, erythema, discharge; systemic fever.
  • Diagnosis: ↑ESR/CRP, WBC; X-ray (sequestrum, involucrum), MRI; biopsy/culture.
  • Classifications: Cierny-Mader (anatomic type), Gustilo-Anderson (open #).
  • Management: Surgical debridement, targeted antibiotics, stable fixation.
• Delayed Union:
  • Fracture not healed in expected timeframe (e.g., 3-6 months).
  • Causes: Infection, ↓blood supply, instability, poor nutrition, systemic factors.
• Non-union:
  • No healing signs for 6-9 months or no progress for 3 consecutive months.
  • Types (Weber-Cech Classification):
    • Hypertrophic ('elephant foot'): Good biology, poor stability.
    • Atrophic ('pencil point'): Poor biology, ↓vascularity.
    • Oligotrophic: Viable, minimal/no callus, often due to large gap.

  ⭐ Hypertrophic non-union typically shows abundant 'elephant foot' callus, indicating good biology but poor stability, whereas atrophic non-union shows no callus, indicating poor biology.

  • Management: ORIF, bone grafts (autograft/allograft), Ilizarov, BMPs, ESWT.
• Malunion:
  • Fracture healed in non-anatomical/unacceptable position.
  • Causes: Inadequate reduction or unstable fixation.
  • Leads to: Functional impairment, deformity. Management: Corrective osteotomy.

Chronic Aftermath - Lasting Limb Woes

• Avascular Necrosis (AVN)
  • ↓Blood supply → bone death. Common sites: Femoral head, scaphoid, talus.

    ⭐ The most common sites for avascular necrosis following a fracture are the femoral head (after neck of femur fracture), scaphoid waist, and talar neck.

  • Classifications: Ficat-Arlet (X-ray), Steinberg (MRI). Imaging: X-ray (crescent sign), MRI (best early).
  • Management: Core decompression, osteotomy, arthroplasty.
• Post-Traumatic Osteoarthritis (PTOA)
  • Causes: Articular cartilage damage, joint incongruity. Prevention: Anatomic fracture reduction.
  • Management: NSAIDs, physiotherapy, arthroplasty.
• Complex Regional Pain Syndrome (CRPS)
  • Types: Type I (no direct nerve injury), Type II (known nerve injury). Diagnosis: Budapest criteria.
  • Stages: 1 (Acute), 2 (Dystrophic), 3 (Atrophic).
  • Management: Multidisciplinary (physiotherapy, medications, sympathetic blocks).
• Myositis Ossificans
  • Pathophysiology: Heterotopic ossification in muscle. Common sites: Elbow, thigh. Brooker classification.
  • Prevention: Gentle ROM, NSAIDs. Management: Observation; excise if mature (typically >6-12 months) & symptomatic.
• Joint Stiffness & Contractures
  • Causes: Intra-articular adhesions, capsular fibrosis. Prevention: Early mobilization, physiotherapy.

High-Yield Points - ⚡ Biggest Takeaways

• Compartment syndrome is a limb-threatening emergency; immediate fasciotomy is crucial.
• Fat Embolism Syndrome classic triad: petechial rash, hypoxemia/respiratory distress, and neurological dysfunction.
• Avascular Necrosis (AVN) commonly affects femoral head/neck, scaphoid (proximal pole), and talus body.
• Nonunion risk factors include infection (osteomyelitis), poor vascularity, inadequate stabilization, and smoking.
• Malunion is fracture healing in an anatomically incorrect position, leading to deformity.
• Delayed union: fracture healing slower than expected for that specific bone.